NYC Top Plastic Surgeon Dr. Keegan on Nipple Sparing Mastectomy

Here is a video of top plastic surgeon in NYC, Dr. Leo Keegan, explaining the steps and risks involved with the new nipple sparing mastectomy procedure. For more information on nipple sparing mastectomies, contact 5th Avenue Millennium Aesthetic Surgery.

Video Transcription:

I’m Doctor Leo Keegan, Plastic Surgeon in New York City.

Nipple Sparing Mastectomy is a new technique that the breast surgeon performs, removing all of the breast tissue but not taking away any skin and leaving the nipple areola complex behind.

As a plastic and reconstructive surgeon, I think there are a number of reasons why we’re seeing more patients who are candidates for nipple sparing mastectomy. Certainly, one of the reasons is early diagnosis. Only certain patients are good candidates for nipple sparing mastectomy; those patients ideally would be those who have either microscopic tumors, or tumors that are at a great distance from the nipple areola complex.

If you think about it, a patient with a large tumor, or one that is in close proximity to the nipple, really wouldn’t be suitable on an oncologic basis to consider nipple sparing approach. There’s some anatomic features as well. If the nipple is already malpositioned and the breast is extremely large then it may not be suitable as an option either.

When a breast surgeon or a surgical oncologist is performing a nipple sparing mastectomy, an incision is made on the breast and there are several different approaches that they may choose from. From a linear incision, all of the breast skin is lifted up, the breast tissue is removed, which is the problem in breast cancer. It’s not the breast skin, but it’s the breast tissue underneath it that’s the problem. If the breast surgeon can effectively remove all of the breast tissue and preserve the nipple areola complex, the cosmesis in many situations can be enhanced.

In a nipple sparing mastectomy the nipple is preserved. The patient will still have a scar and the different approaches would include a radio-lateral incision, which would be made at a point lateral to the nipple areola complex or in the inframammary fold, which is a little bit more concealed but maybe more difficult to reach the upper pole of the breast.

The reconstruction can often be superbly performed and the cosmesis significantly enhanced. I like to think that I can make a very nice reconstructive nipple, but I can never make it a nicely as the original nipple was.

There are several features that have to be considered before one is a candidate for nipple preservation. The most important aspects are always the oncological aspects. Nothing that we want to propose, either on the reconstructive side, should ever interfere with the patients appropriate oncologic care. This takes first place, second place, third place. The reconstructive options in the aesthetics of the reconstruction are quite important but take a distant back seat to the oncologic concerns.

So the overriding issue of whether a patient is a candidate for nipple sparing mastectomy is the oncologic issues. When I say that, you have to have a patient who has a small tumor, the tumor has to be at a distance from the nipple, so it can’t be underneath the nipple or in close proximity to it, or the patient has to be a patient who is having prophylactic surgery. We’re seeing many many more women who have genetic mutations and were candidates who were considering prophylactic mastectomy, and in many cases they can be excellent candidates to consider nipple sparing approach.

Before undertaking a nipple sparing mastectomy approach, a lot of discussion needs to take place between the patient’s breast surgeon as well as their reconstructive surgeon. Risks include oncologic risks and as we talked a short while ago, the patient has to be an appropriate oncologic candidate. It should not be an option that’s offered to somebody who has a large, or locally advanced tumor, or someone who has a tumor that’s in proximity to the undersurface of the nipple. You’re not going to do something for aesthetics that would impair their appropriate treatment of their cancer. That’s probably the biggest risk that one has to consider. Other risks that need to be considered are the anatomic issues, the size of the breast and the location of the areola complex.

If the breast is extremely large or the nipple is malpositioned in a todic location then the blood supply to that nipple may be somewhat compromised as a result of the mastectomy. Or if the nipple is malpositioned to begin with, where will the nipple be after the reconstruction? Will it continue to be malpositioned and therefore aesthetically unsuitable, or will it be able to be elevated slightly to a more appropriate aesthetic position? These are issues that have to be discussed between the patient and their surgeons.

A brief summary, the oncologic risks are very important and must be, the patient has to be an appropriate oncologic candidate to proceed in this manner; and then the anatomic risks in terms of the blood supply to the nipple, it’s viability and it’s location. Essentially, in a nipple sparing mastectomy the nipple and the areola complex simply become specialized breast skin. It does not have sensation. It will have blood supply as the rest of the breast skin will have that comes through the subdermal plexus but there’s no direct blood supply that ordinarily comes through the breast tissue itself.

When patients undergo nipple sparing mastectomy the results can be phenomenal. We’ve done reconstructions with patient’s who’ve had nipple sparing approaches with implant base reconstructive options or with autologous tissue reconstruction, such as the DIEP flap. In both scenarios, reconstruction can proceed and results can be aesthetically most pleasing.

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